Course Pediatric Disaster Behavioral Health (PDBH) Toolbox

This primer provides key information regarding the purpose and role of a hospital-based telepsychiatry program, benefits, and impacts of telepsychiatry in pediatric emergency settings,  best practices to secure buy-in from both administrative and clinical staff, important program requirements, best practices for sustainability, and potential pitfalls. 

Overview

Several formats of telepsychiatry exist, including:

• Direct patient assessment from a remote site into a clinical setting or into the home
• Provider to provider consultation
• Psychoeducational forums
• Combinations of these, including asynchronous consultation

Consultation often includes:

• Assessment and diagnostic formulation
• Psychopharmacologic considerations
• Assistance with determining indicated levels of care
• Specialized crisis resources to enable safe disposition

Why is it needed?

• EDs have become the de facto referral destination for patients with suboptimally managed acute behavioral health needs.
• Local hospitals often lack adequate space and resources to assess and treat youth with mental and behavioral health emergencies.
• Limited access to appropriate treatment settings contributes to prolonged boarding times and delay in definitive care.
• Psychiatric boarding can be further destabilizing to patients in behavioral crises and impact care provision for all patients presenting for emergent care.
• Psychiatric illness may be comorbid with medical emergencies that require highly integrated care, and telepsychiatry consultation can be rapidly utilized to help determine the need for emergent management or identify approaches to optimize treatment approaches.
• Delays in accessing clinical expertise or alternative care settings can also increase risk of consequences such as medication errors, use of restraints, and moral distress in families and clinical staff.
• Disasters will likely exacerbate the need to utilize telepsychiatry services to maintain ED readiness by offering more rapid assessments and triage to psychiatric services due to escalation in symptom prevalence, complexity, and acuity.

Benefits and Impact of Telepsychiatry in Pediatric Emergency Settings

Initial results across a number of studies evaluating the clinical effectiveness of telepsychiatry have demonstrated positive findings in terms of:

• diagnostic reliability
• clinical effectiveness
• implementation feasibility
• patient satisfaction

Research findings indicate that implementation of telepsychiatry into pediatric emergency settings results in enhanced outcomes, including:

• significantly reduced ED lengths of stay
• reduced inpatient psychiatric admission rates (and associated need for transport to alternative care settings)
• substantial cost savings to families
• reduced lengths of stay in subsequent inpatient settings once these are accessed
• improved engagement in outpatient settings following discharge from the ED

Best Practices to Get Buy-in from Administrators

1. Describe potential benefits to patients and families
   • Improved patient experience and satisfaction
   • More timely care and decreased length of stay
   • Increased access to staff with specific expertise in behavioral health
   • Reduced need for transport to alternate care settings
   • Introduction to the modality of telepsychiatry, which could enhance feasibility and access to subsequent outpatient care.
2. Describe potential benefits to the ED and hospital system
   • Improved ED throughput due to more timely assessments and increased access to specialized care coordination
   • Improved ED readiness
   • Improved ED patient safety and satisfaction
   • Establishing clinical connections to broader care networks to enable access during future surges and disasters

Best Practices to Get Buy-in from Clinical Staff

In spite of high patient satisfaction, ED clinical staff tend to be more reluctant to embrace telehealth, often citing concerns of risking rapport and frustrations around technological hurdles. This tends to improve with greater familiarity and engagement; higher clinical staff satisfaction is seen not only from training but from supervised care provision. Successful implementation can be fostered by normalizing the utilization of telepsychiatry to improve access and patient care.

More specific strategies include the following:

1. Create a committee
2. Provide clear and user-friendly instructions
3. Emphasize improvements in employee experience
4. Ensure continuous training
5. Invite experience sharing

Important Program Requirements

Legal Requirements

Verbal and/or signed consent for telepsychiatry services is needed and should be developed in accordance with the requirements of your hospital system and/or jurisdiction. Assure that telepsychiatry clinical staff are licensed in the state where your patients will be located. Depending on the model of care, credentialing at multiple institutions may be required.

Clear and Detailed Program Design

1. Define who will qualify for telepsychiatry with clearly defined inclusion and exclusion criteria. For example, what level of cooperation or competence will be required for a patient to receive telepsychiatry services? What level of agitation or symptom complexity will exclude a patient?
2. Outline specific steps to set up a telepsychiatry consult. For example, notification of psychiatry staff of need for a consultation, placement in the consult queue, setup of video conference technology, etc.
3. Establish transfer agreements for admissions or transfers to outside facilities that do not violate HIPAA requirements.
4. Determine how parents may be included in the evaluative and consultative process

Physical Space

1. Identify a safe space for psychiatric patients that is free from potential physical dangers. This should be a private area for evaluation, away from other patients, staff, or family.
2. Designate a second private space to obtain collateral from family members.
3. Develop a safe space to charge the electronic devices

Informed Patients and Families

Disseminate materials for families who may receive telepsychiatry services to help them understand the benefits, the scope of the program, and the boundaries of privacy and confidentiality. Consider utilization of cultural navigators and longitudinal case management to support engagement and comprehensive care.

Best Practices for Program Sustainability 

Effective Connection

Provide an easy-to-access communication platform, capability to escalate if the connection is disrupted, and IT support for common barriers. Maintain updated internet connectivity and utilize sturdy technology with backup supply available.

Flexibility

Provide flexibility of care delivery, including phone backup if Wi-Fi is down or the tablet screen breaks, or when the modality is not addressing the needs of the patient.

Safety and Confidentiality

Ensure safety and confidentiality by providing a private space for consultation as well as a facilitator to enable individual interviews. Ensure that privacy of medical information can be maintained.

Personalization

Ensure personalization during clinical encounters. For example, consultations should not be rushed, records should be reviewed before the interview, and providers should practice trauma-informed and culturally sensitive care.

Therapeutic Quality

In addition to personalization, ensure therapeutic quality and patient engagement with real-time feedback and exhibiting interpersonal sensitivity and empathy through the course of the interview. Tailoring emotional attunement and language style to developmental level is also important. 

Processes and Scope

Clearly define consultation processes and scope of care. For example, provide guidance and implement workflows to address findings of abuse, acute suicidality, or medical acuity warranting further evaluation before recommended psychiatric treatments can be determined.

Sustainable Economic Foundation

Build a sustainable economic approach to implementation including design of clinical note templates with appropriate billing elements and easy incorporation of relevant consent attestations. 

Resources and Training

Develop simplified job aids with easy access that include use of the equipment in addition to tips on engaging youth and their families. Build sustainable strategies to manage staff turnover and flexible staffing models, such as train-the-trainer and standardized clinical workflows.